Ep 213 Burns Part 2: It’s like sci-fi but real

a week later, I had my first surgery. The first procedure was extensive wound abreadment that couldn't have been achieved while I was awake, and the application of homographed, which is essentially a very fancy band aid that's cadaver skin. A couple of days later, after allowing the wound site to calm down a little bit, the homograft was removed and something called BTM, or biodegradable temporizing matrix was placed

on the burn site. BTM is an incredible innovation. It's basically a sort of foam that acts as a structure for the body to rebuild tissue into over time. Over a period of several months, the BTM then dissolves, leaving just the newly grown tissues. After the BTM was placed, I went home for about a month to allow the sites to mature. During this time, I had to rinse the wound and the BTM every four hours with dake In solution, which is a diluted bleach concoction that's been

in use since the Civil War for wound care. After a month, I went in for my third and final surgery. My surgeon took a skin graft from the right guy and applied it to the matured BTM. Watching the graft's heel and adhere to the healthy tissue around the wound site was really incredible and honestly felt miraculous. I eventually was made custom compression gloves and got to attend hand therapy, and about three months after my injury, I was able to return to work. But never fear. I don't work

on that machine anymore. We keep a distance from each other. I'm very happy to say that I've had a really good outcome. I'm very fortunate to have an incredible risk of motion and good strength in my hand, to the point that I don't have to think about my injury most days. Dealing with the immediate aftermath of a burn is really difficult.

it takes to endure that every day. I also want to take a moment to recognize and emphasize the importance of workers compensation. Without workers' compensation, the cost for burn treatment and wound care supplies would have been astronomical. It's so important that workers have access to medical care and financial support to help them recover from injury. Sustained at work and receive long term care for any lingering complications.

check it out. You really sold that about us page? There? Do we even have like the start date of the podcast, which still blows my mind that we are in our ninth year of doing.

So but for that entire time that we covered, burns remained pretty much beyond the reach of medicine in nineteen hundred, those who were under sixty one years of age who had burns covering more than twenty five percent of the body surface. Of those, one hundred percent died. Wow. One percent in nineteen hundred, twenty five percent total body surface area. Wow, in adults under fifty under sixty one.

make tremendous strides up through the present day. And I'm going to leave those present day strides to you, Aarin, And what I want to focus on instead is those fifty or so years what changed in medicine to drive such a transformation. There was no oh, single moment or breakthrough, but there were many. There was skin grafting, antiseptic technique,

fluid balance and nutritional support, antibiotics, and airway management. Really it was through integrating all of these medical advancements, through the formation of burn care as a specialized approach, that the scales finally tipped. The survival rates that this integrated management could now achieve were beyond the imagination of any

physician in past centuries. Like I imagine someone trying to treat someone with a burn in like fifteen hundred and then coming today to a burn center and just just like chills that. It's amazing to think about how much.

over the nose wound. Fascinating. Yeah, So skin grafting in that way has very very deep roots. Wow. And from this point until the eighteen hundreds, a few physicians had tried their hand at grafting over the centuries, with varying rates of success. Allegedly, the first rhinoplasty I think was performed in the sixteen hundreds or sixteenth century, I can't remember, Okay,

like a while ago, Yeah, a while ago. Yeah. But still it was very much touch and go, not very It was definitely more of an art that a science, and things turned around in the eighteen hundreds. The early part of the century saw a few surgeons experimenting with skin grafting in animals, which showed some promise, but more importantly those experiments helped to clarify some crucial concepts about

tissue death, circulation, and immune rejection. What's actually going on in the wound healing process, and what's necessary for the skin graft to actually take right.

let's run the full gamut here. This free skin grafting technique was first applied to burns in eighteen seventy when a surgeon named G. D. Pollock treated his eight year old patients thigh burn by transplanting skin from her abdomen to the wound, and after six weeks the grafts looked

pretty excellent, which is kind of incredible. Yeah, skin grafting became really popular and other surgeons refined various techniques like the split thickness skin graft where you take bits of the dermis along with the epidermis, and this technique promoted faster healing and less scar formation, which reduced scar contractures, which also you'll talk about.

By the early nineteen hundreds, grafting and burn decision with a wound decision was they were pretty well established techniques. But no matter how skillfully you grafted or debrided, if your instruments weren't clean, if the wound wasn't clean, infection often led to death. Aniseptic technique. This is like a mini history of many different medicine.

Fifteen and you haven't rinsed your hands once? That's what I want in a surgeon.

Later during World War One, other antiseptic solutions were developed, like boric acid, acetic acid, and a twenty five percent solution of sodium hypochlorite also called Dakin solution. Still use that today, Still use that today. Antiseptic technique was a major step forward in reducing infections and deaths following surgery, such as removing burnt tissue or performing skin graphs, and the same principles were used for wound management in burn

patients even if they didn't have surgery. Because your skin, as you've talked about, is a barrier to infection. When that barrier is disrupted, it leaves it super vulnerable to infection. And so if you can find a way to decrease that vulnerability through aniseptic ointments, antimicrobial ointments, bandages that are infused with antiseptic components, stuff stuff. These things are integral in improving outcomes for those who have burns, both minor

and major. By reducing infection through aniseptic technique and these specialized ointments, physicians could chip away at one major major source of mortality for burns, but other threats remained. Fluid balance and nutritional support. Yeah, yeah, this is a big one, more than I realized. I think, despite having rewatched all of ER, I don't think it really hit home to me how important this part of it was. As though ER is a super super accurate It's like I'm saying,

despite med school to bite er same same. Over the centuries, a handful of physicians had noticed that providing a burn patient with lots of replenishing fluids and food seemed to help. But this was very much against the beliefs of the day. Things like blood letting and purging were still the standard for centuries, and it wasn't really until the late eighteen hundreds, the late eighteen hundreds that doctors began to crack the code on fluid balance and nutritional support.

the blister. Yeah. And some people then tinkered around with fluid replacement with saline administered orally, rectly or intravenously, But it wasn't really until World War One that the technique was refined, and not until nineteen twenty one that it

was applied systematically to burn patients. Okay, so that year a fire broke out at the rialto Theater in New Haven, Connecticut, and a professor at Yale, Frank Underhill, saw that the composition of fluid and blisters was the same as plasma, and loss of those compounds, he suspected is what led to shock in burn patients, and so he was like, I think that this is actually causing that fluid loss

is causing mortality in burn patients. It's not toxins. So previously it was believed that toxins were the thing that killed people, which it can still be if you think of toxins as like bacterial infection or fung infact, that.

About a decade after the rialto Theater fire, which happened in nineteen twenty one, physicians began to notice that burn patients also needed an increased caloric intake, and that extreme loss of lean body mass put them at high risk for poor outcomes. So death decreased wound healing, impaired immunity, and so on. So the nitty gritty of how to best provide adequate nutrition and calories that took decades to figure out or again consensus on, but the recognition of

this issue was absolutely critical. Next up is antibiotics. Antisepsis and antimicrobial dressings were a huge step forward, but they didn't always entirely prevent infection. The development of penicillin in the early nineteen forties, I mean, it was discovered in nineteen twenty eight, but it wasn't widely available until the war ended in nineteen forty five, and then later broad spectrum antibiotics. This really helped to control infection when it

did arise in burn patients. One of the very first uses of penicillin in the general public was, in fact, after the Coconut Grove nightclub fire in Boston on November twenty eighth, nineteen forty two. Huh, Yeah, I didn't know that. Yeah, I think I feel like I remember talking about it in our Antibiotics episode, and you.

and the recognition of airway injuries after a fire. Yeah, and so but since since then, since this nightclub fire, antibiotics have often been employed in treating systemic infections that arise after a burn, or used prophylactically to prevent infection in the first place. But their use in burn patients can be tricky. So, first, antibiotic resistance is a major problem,

especially for certain types of bacteria found after burns, like pseudomonous. Yeah, and antibiotic use can also lead to other opportunistic pathogens taking over, so for example, certain fungal species such as Canada albacans. So it's it's not, it's not it's a little bit of a mixed bag, or it's like, it's not, it's not the way that antiseptic technique or fluid replacement is the role that it plays in the history, especially because.

made note of this quote. It was obvious almost at once that we were dealing with something more than the problem of burned skin. A severe impairment of respiration also existed. End quote.

But really, like what you can kind of see is the pieces of all of this, like, Okay, well, we're relieving the threat due to fluid imbalance, We're relieving the threat due to infection in the wound directly, we're relieving the threat of all of these different things and kind of saying, okay, what's left that we can improve upon? And that's how the history of burn treatment kind of goes.

And it's a lot, right, Like it's a lot, even though I haven't been talking for all that long compared to somehow sometimes how I go on and on, there's I'm sure that you've already forgotten the details of how fluid replacement was discovered or the earliest skin graft performed, And if you have forgotten, don't sweat it, like that's you don't need to remember the details. The important thing that I want everyone to take away from all of this is kind of what I already said at the top.

It's not one thing that changed the landscape of burn care. It's many things, not working in isolation, but coordinated care. At the end of the nineteen forties, researchers had made all of these incredible advancements that made survival after a

severe burn more possible. But one last step remained before possible turned into probable, and that was the formation of burn units or burn centers, coordinated round the clockcare that integrates expertise across many different disciplines, working as a team. The first burn units in the United States were founded in the mid twentieth century, and they have transformed burn

care and offered tremendous hope. They also act as a research unit, constantly striving to improve not only survival, but quality of life, pain management, psychological trauma, stigma, physical therapy. At these centers, people with burns are treated not in

pieces but as a whole. And as we've gotten better at managing the immediate injury, at managing the physiological impact of burns, it has also left us more able to address and improve the injury to the parts that you can't see, like the huge trauma that happens, the stigma, all of these different aspects, and I just like, especially after doing these episodes, really want to acknowledge the incredible work of the healthcare professional at these centers because it is crucial what they do.

past century. Continued improvement can only be achieved through funding for research. And I know everyone who's listening has heard this all before, but I just it bears repeating, like it bears repeating until we all internalized tel something changes, what changes. But with that, Aaron, I'll turn it over to you now to fill us in on some of the incredible treatments out there for burn injuries that happened after those fifty years.

that is imperative. So I'm not, you know, knocking the importance of that. But what I want to really focus on is the long term on how we treat these burn wounds to heal them over time. Because the technology that we have now to improve upon these outcomes is really truly phenomenal, and it builds on everything that you talked about already erin. So the first part is the surgery, and this idea of surgical excision is a mainstay of

burn care. For anything that is a deep partial thickness, so a to be a second degree like a deep second degree burn, or worse, a third degree or down into the muscle or bone tissue, surgical excision early is a mainstay. Exactly when and exactly how early depends on the burn center depends on the situation, but usually within the first day or two or three to remove all

of the dead or necrotic tissue. What this does is it helps to ensure that the surrounding tissue has less damage because remember we talked in last episode about how there's kind of a zone around the worst part of the burn that is really at risk of further damage. So by removing the necrotic tissue, we can help to kind of keep that tissue viable. And this can go

in a lot of different ways. So sometimes it means like actual surgery with like sharp instruments where things are kind of scraped away down to healthy bleeding viable tissue.

Sometimes it might mean newer technology like water, like high pressured water we now have, which is fascinating, and that's to basically like go through the planes of tissue, but in a way that causes hopefully less damage to healthy tissue, because it can sometimes be really hard to tell apart healthy tissue from dead tissue.

both next and at the same time. So that means washing wounds right to remove any remove any debris, and then covering wounds whether they needed surgical excision or not, with antibiotic infused dressings or ointments or.

growth of bacteria to reduce the chance of infection. IV antibiotics, like I mentioned, we don't tend to use unless there is an infection that leads to something like sepsis, because not only is it overboard to use ivy antibiotics that might increase the risk of antibiotic resistance and other things, but also these wounds don't really have any blood flow, so IVY antibiotics don't really work.

The way that we do skin grafting today is mostly by what's called a split thickness skin graft, so that means a skin graft that has both epidermis and a small amount the very top of the dermis. For more sensitive areas or more cosmetically important areas like say the face or maybe even the hands, you might use a full thickness skin graft, so that would be epidermis and the whole entirety of the dermis. And skin grafts are

really fascinating. You could probably talk in way more detail about them, but I will just give us all the basics of how these work. Essentially, you take a healthy, non burned piece of skin and use that to cover the burned wound. You adhere it with staples or sutures or something. Ideally the skin comes from you, yeah, because then your body recognizes it and there's much less risk of rejection or anything like that. There's two ways that we can do this, depending on how important the cosmetic

outcome is and how large the burn wound is. In some areas, you might take a piece of skin and just use it as is to cover sort of just like a flap graft essentially. Okay, in other cases, you might do what's called meshing, which means you take the skin that you're going to use as the graft and you run it through a machine that basically turns it into a mesh so that you can stretch it over a much larger area. Your face doesn't look like it appreciates that.

took a section of his skin. And then on his lower leg he has a wound that is it's a little bit deformed because his wound was all the way down to the muscle basically, but it also is a bit stippled looking like it's you can tell that it wasn't like completely covered, and that's because that was meshed, and so he had this mesh covering of his own skin that covered that wound while it was healing.

that ideally skin grafting would be done. But in many cases someone might not have enough skin, maybe their burn area was really really high, or maybe they're just not very stable, they're super sick at the time, and so we don't want to risk a prolonged surgery where we also have to take skin from other areas to try and make it into a graft to cover, and so in those cases we might use what's called an alo graft,

which means skin from someone else. Usually it's a cadaveric skin graft, or sometimes even zenografting, which is with another animal's skin, so something like poresine skin or something. These are usually temporary because usually our body is going to reject them in one way or another, and so they act as a covering, but often have to be removed after a couple of weeks or so, or if there's any signs of infection.

there to act as essentially skin substitutes. Okay, whether a skin graft isn't possible, or whether you know, maybe something wasn't quite enough to warrant a skin graft, but you're worried that the healing process is still going to take a really long time, and dressing changes are incredibly painful and can be really distressing, and so a lot of these other skin substitutes, even if they're not taking the place of a graft, maybe they're used while we're waiting

for a graft. Maybe they're used in a place to reduce the need for frequent dressing changes. Even if we don't need a skin graft later on. There's some really incredible things. Some of them are still in the realm, not of science fiction, but of more research, and some of them are already accessed, like commercially available, and if you have access to a great burn center that actually can get them, then you can get them. So let's

talk about what some of these might look like. Some of these dressings might be made from natural polymers like kitan, which is fascinating, like from an insect exoskeleton and things like that, right, Okay. Some of them might be made from cellulose from plants, or even like fibrine or hyaluronic acid, collagen, gelatin, any kind of polymer that you can think of that might come from nature. And others are from synthetic polymers,

something like silica or maybe synthetic carbon based compounds. And these dressings can come in a really wide variety of textures. Some of them are what are called hydrogels, which still take me. I still can only barely understand them because they basically are these things that help to soak up fluid in the wound, so they reduce how wet that wound is going to be, and then they by hydrating themselves. They also like their properties become more available to your skin or to your healing wound.

impair wound healing. You need to be able to have oxygen flow in and out, so you need something that's semi permeable like our skin is and prevents infection. Right, So something that's going to block other either have antibiotics in it or can just block other microbes from getting in. And ideally these dressings can also help to reduce pain either because they have something in them that's analgesic or just because they're reducing the number of dressing changes and

the friction or anything that you might have from other dressings. So, like I said, there's two, there's literally too many of these kinds that can go into these. One that I think is quite interesting is an acellular fish skin.

one of the newest ones for me. But then there's also a lot of interest in things that are even more They honestly sound like science fiction y. So there are things that are available actually that are kind of like scaffolds that we actually can take some of our own cells, send them off to these companies who engineer them and then spray them or or otherwise infuse them into these like films, these scaffolds that we then can use as addressing.

these different things airway management, and then now we have a lot of those things more under control, right, can go back to the burn and say, I mean, I know it's all been done simultaneously, but like we're now kind of some of the most exciting researches in this area of how do we promote healing again fixing exact on that burn itself on the toxic local area, right.

is skin grafts. So if you cannot take skin from yourself to be able to do a skin graft, then one of the most common complications of burn wounds is what's called hypertrophic scarring. And hypertrophic scarring is as high as seventy percent in people with burn injuries. And basically what happens is that as the scar forms, it is laying down collagen in this like linear way that ends up lacking the flexibility of uninjured skin.

really itchy. This is different, by the way, than a keyloid scar, which can also be a complication of burn injury. But keyloid scars grow beyond the edge of the initial wound, and that's because of them being stuck in that proliferative phase of wound healing and not moving on to this remodeling phase of typical scar formation. So certain types of skin might be more prone to keloids than others, but overall all, burned skin is very prone to hypertrophic scarring.

And both keyloid scars and hypertrophic scars can be painful, they can be hugely impactful on quality of life, and they're really hard to treat after the fact. Additionally, what happens as this like dysregulated collagen is being laid down, is that you also have what are called myofibroblasts that are being laid down. And these are cells that our body uses specifically to close up the wound bed itself. So,

like you said, are they just trying to get it done? Yes, And so our body uses these cells that try and decrease the area of the wound by contracting it, and that can result in what are called contractors. And you've mentioned these a few times erin, but these are basically scars that can form that are very tight and painful, and especially in an area where you need to have movement, like your hand or your face, I mean almost anywhere on your body your skin needs to be able to move.

That can really impact quality of life and like the ability to do the things that you need to be able to do. In general, the deeper the wound, So the deeper the burn, the worse likelihood there is for scar formation or like the more likely you are to have bad scars.

Those are our pigment producing cells, and so that's why a lot of times we see changes in pigment and then yes, like our body is healing by scar formation, especially if you have lost them the skin stem cells to where you're not fully regenerating the skin that was there before, but you are instead filling it with scar It's like it is a different tissue than the skin was initially.

So the World Health Organization reports that globally there's at least eleven million people who have burns bad enough that they are being reported, which likely means that they are severe, so more than ten or twenty percent of your body surface area.

is severe burns, not just burn burns. Mortality rates from burns have dropped substantially in high income countries, but that's to a much greater degree than the decreases in mortality in low and middle income countries. We also see a bimodal age distribution in who is most likely to have burns.

Young children under age five and working age adults are the two highest groups that suffer from burns, and like I said in last week's episode, flame burns and scald burns are the most common types of burns, with chemical and electrical burns being relatively rare, and kids under age five are more likely to get scald burns than flame burns,

so from hot water and things like that. In the US, where we have a little bit more like hard data, it's estimated that more than half a million people seek medical treatment for their burns each year.

profound effect on people's mental health health. And I don't want to discount the effect on the health of caregivers, the care of people who have had burn trauma is very prolonged, it can be very intensive, and that can be really hard on caregivers, especially if you don't have access to something like a specialized burn center, which even in high income countries, over twenty percent of the population in this country does not live within two hours by

ground or air of a burn center, which means that they don't have access, and that's in a high income country. In low and middle income countries, they have even less access. So there's been a lot of research too on people who have suffered burns, people who have been caregivers of people with burns, and people who care, medical professionals and things on what do we need to do, what are

the priorities in burn management? And the biggest ones that have been identified so far are improving the actual wound management, and so that's where I think most of the research that I have seen has really been in, which is like wound dressings and skin substitutes and all of these things. But the second most common response was improving psychosocial outcomes, yes, which I think that we have done maybe less of

a great job of focusing on so. And then other things like rehab and helping to treat scarring after the fact were other things that were identified as kind of high priorities, And I think it shows that when we have access to dedicated facilities, to teams who are really experts in burn care, and to these incredible technological developments and advancements that we've seen, there is the potential for the treatment of burns to be phenomenal.

burns has changed. And then by Jackson nineteen ninety one the evolution of burn treatment in the last fifty years. So from that's interesting paper. Then by Barrow and Herndon. I think it's a book chapter called history of Treatments of burns.

couple from the Lancet. One that was from the Lancet Global Health that I mentioned that was called the top ten research priorities in Global burns Care. So that one was kind of how we need to focus on burn care going forward. Another one just specifically on hypertrophic scarring and how much we need to focus on that. A whole other paper on nanotechnologies. Oh my gosh, there's so much more. You can find them all on our website, this podcast will Kill You dot com under the episodes tab.